Nursing Elites

1. A client is complaining of pain in his right hand after surgery. The IV in his hand has slowed down, and the skin around the site is reddened and cool. The client reports localized pain in the hand and fingers. What is the most likely cause of this client's pain?

• A. The client's IV is infiltrated
• B. The client is experiencing phlebitis from the last drug administered
• C. The client has a blood clot developing in the distal arteries of the wrist
• D. The client's pain is associated with myocardial ischemia and he is having a heart attack

Correct answer: A

Rationale: Pain, cool skin, and edema at an IV injection site indicate IV infiltration. The reddened and cool skin around the IV site, along with localized pain and a slowed IV drip rate, are classic signs of infiltration. Infiltration occurs when IV fluids or medications enter the surrounding tissues instead of the vein, leading to potential tissue damage. Phlebitis is inflammation of a vein, not infiltration. A blood clot in the distal arteries of the wrist would not cause these specific symptoms. Myocardial ischemia and heart attack are unrelated to the client's localized hand pain and IV issues.

2. While measuring a patient's blood pressure, which factor influences a patient's blood pressure?

• A. Pulse rate
• B. Pulse pressure
• C. Vascular output
• D. Peripheral vascular resistance

Correct answer: D

Rationale: When measuring a patient's blood pressure, it is important to consider various factors that influence blood pressure. Peripheral vascular resistance plays a crucial role in regulating blood pressure. The level of blood pressure is affected by factors such as cardiac output, peripheral vascular resistance, volume of circulating blood, viscosity, and elasticity of the vessel walls. Pulse rate (Choice A) refers to the number of heartbeats per minute and is not a primary factor influencing blood pressure. Pulse pressure (Choice B) is the difference between systolic and diastolic blood pressure and does not directly impact blood pressure regulation. Vascular output (Choice C) is not a recognized term in blood pressure regulation and is not a primary factor affecting blood pressure.

3. Which of these actions illustrates the correct technique for a nurse when assessing oral temperature with a glass thermometer?

• A. Wait 30 minutes if the patient has ingested hot or iced liquids.
• B. Leave the thermometer in place for 3 to 4 minutes if the patient is afebrile.
• C. Shake the glass thermometer down to 35.5�C before taking the patient's temperature.
• D. Place the thermometer at the base of the tongue and ask the patient to close his or her lips.

Correct answer: B

Rationale: The correct technique for assessing oral temperature with a glass thermometer involves leaving the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile. Waiting 30 minutes if the patient has ingested hot or iced liquids is incorrect; instead, the nurse should wait 15 minutes in such cases. Shaking the glass thermometer down to 35.5�C, not 37.5�C, is the correct procedure before taking the patient's temperature. Placing the thermometer at the base of the tongue, not the front, and asking the patient to close their lips is the proper way to position the thermometer. Therefore, the correct answer is to leave the thermometer in place for 3 to 4 minutes if the patient is afebrile and up to 8 minutes if the patient is febrile.

4. The abbreviation pc is defined as ________________.

• A. before the meal
• B. with the meal
• C. after the meal
• D. post corpi

Correct answer: C

Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.

5. In addition to standard precautions, the nurse caring for a patient with rubella would plan to implement what type of precautions?

• A. Droplet precautions
• B. Airborne precautions
• C. Contact precautions
• D. Universal precautions

Correct answer: A

Rationale: Rubella is an illness transmitted by large-particle droplets, so the nurse should implement droplet precautions in addition to standard precautions. Airborne precautions are used for diseases spread through small particles in the air, such as tuberculosis, varicella, and rubeola. Contact precautions are utilized for diseases transmitted by direct contact with the patient or their environment. Universal precautions and body substance isolations are part of the CDC's standard precautions recommendations, but do not specifically address the transmission route of rubella.

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